In the event of DENIAL based on reasons other than medical necessity, such as non covered services, the health maintenance organization must give the provider initiating the request for authorization, and the enrollee if he or she requests it, a written denial response that indicates where to initiate a request for an informal complaint or a formal complaint. The written denial response shall include the address, telephone number and title of the individual or the specific department within the health maintenance organization to whom the request may be made.
After notification to the health maintenance organization and a reasonable opportunity to cure, the Alabama Department of Public Health may recommend to the Department of Insurance the withdrawal of a previously approved service area if required provider access is not maintained.
Author: Department of Public Health
Ala. Admin. Code r. 420-5-6-.06
Statutory Authority:Code of Ala. 1975, §§ 22-2-2(6), etseq., 22-21-20, etseq., 27-21A-1, etseq.